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Depression: from Children through Adults

By Barbara Romano, PhD

Depression is a commonly used term to describe a dysphoric mood state. Clinically, however, the symptom of depression is part of a set of symptoms which comprise a clinical disorder. Three commonly diagnosed non-bipolar depressive disorders are (1) major depression, (2) Dysthymia, and (3) adjustment disorder with depressed mood.

According to the diagnostic manual used by clinicians (DSM-IV, APA, 1990), a major depressive episode lasts at least two weeks and is characterized by one of the following: (1) depressed mood (or irritability in children & adolescents), or (2) significant loss of pleasure or interest. Five additional symptoms must also be present nearly every day. These may include significant change in weight, or in children, failure to make expected weight gains; insomnia or hypersomnia; psychomotor agitation or retardation; fatigue or loss of energy; feelings of worthlessness or excessive guilt; diminished ability to think or concentrate, or indecisiveness; recurrent thoughts of death or suicide, or a suicide plan or attempt.

Although these criteria are used to diagnose a major depressive episode in children, consideration of a child's developmental level is important. It may be more difficult to identify depressed mood in children because their normal mood state is more elevated as compared to adults. Therefore, a neutral mood might be viewed as a depressed mood since it is a deviation from normal exuberance. In addition, mood states in children are more likely to shift rapidly in response to environmental stimuli As children develop into adolescents, the syndrome of depression is more characteristic of that seen in adults.

Dysthymia is not as severe as major depression. Depressed mood must be present most of the time for at least two years. In children and adolescents, the mood can be irritable and last at least one year. In addition to the symptom of depression, two or more of the following must be present: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness.

An adjustment disorder with depressed mood is a reaction to an identifiable stressor. Once the stressor has terminated, the symptoms of depression, by criteria, does not persist for more than six months. However, the disorder may be considered chronic (lasting more than 6 months) if the duration of the stressor or its consequences is enduring.

Depression is most likely due to the interaction of a number of factors. These include biological, cognitive, behavioral, and environmental factors. The biological model of depression hypothesizes that depression is linked to abnormal functioning of neurotransmitter receptors in the brain.

The cognitive model of depression suggests that depressed individuals have dysfunctional attitudes about themselves, the world, or their future (Beck). When faced with an environmental stressor, the individual perceives the situation in a negative manner which can lead to depressive symptoms. A related cognitive model of depression is "learned helplessness" (Abramson, Seigman, & Teasdale). This model suggests that depressed individuals attribute the causes of negative events to internal, stable and global factors.

The behavioral factors of depression include poor social skills and limited skills for coping with stressful life events. Studies have shown that depressed individuals are more unassertive, make more negative self-references, may isolate themselves or put themselves in a position to be socially rejected than nondepressed individuals.

The most commonly used biological treatment for depression is antidepressant medication, which corrects the dysregulation of the neurotransmttter receptor sites. The most effective psychosocial treatments have included cognitive-behavioral therapies.

Patients are taught to understand the relationship between events, emotions, and cognitions. They are instructed on identifying, evaluating, and modifying automatic negative thought patterns and their underlying assumptions. Behavioral treatment may also include stress management training, assertiveness training, social skills training, and activities training.